Surgery versus percutaneous transcatheter embolization for pulmonary arteriovenous malformation: Analysis of a national inpatient database in Japan

Transcatheter closure of a huge complex pulmonary arteriovenous malformation with four devices: a case report

Pulmonary arteriovenous malformations are abnormal vascular connections between pulmonary arteries and veins, often causing right-to-left shunting. In this report, a 4-year-old boy with low oxygen saturation was diagnosed with a large, complex pulmonary arteriovenous malformation involving four feeding arteries. Percutaneous transcatheter closure was performed using four devices to occlude the major feeding arteries, resulting in increased arterial oxygen saturation from 72 to 98%. This report depicts the successful use of multiple devices for percutaneous closure of a complex pulmonary arteriovenous malformation in a child and highlights the minimally invasive and effective nature of this approach.

Pulmonary arteriovenous malformation causing lung sequestration and media infarction: a case report

Pulmonary arteriovenous malformations (PAVMs) are rare vascular malformations of the lungs. Direct communication of pulmonary arteries to pulmonary veins is the defining characteristic allowing venous blood to bypass the pulmonary capillary system and avoiding an efficient oxygenation process. The complexity of the pathology lies not only in the variety of its manifestations, but also in the choice of the most appropriate and effective treatment. We present a case of a complex PAVM associated with a persistent foramen ovale, with stroke as the onset symptom. Despite timely multidisciplinary treatment of the malformation, a potentially fatal pulmonary complication occurred, highlighting the critical importance of early, interdisciplinary management and ongoing follow-up of PAVMs, particularly in preventing life-threatening outcomes.

A Meta-Analysis and Meta-Regression of Embolisation Outcomes of Pulmonary Arteriovenous Malformations

PURPOSE

Embolisation is a widely utilised therapeutic intervention for pulmonary arteriovenous malformation (PAVM). We conducted a meta-analysis to evaluate outcomes of PAVM embolisation and factors associated with embolisation outcomes.

METHODS

MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials (CENTRAL) were searched from 2000 to July 2022 on studies that assessed embolisation outcomes of PAVM. Immediate technical success rate defined as the complete occlusion of the PAVM at the time of embolisation and treatment success rate defined as ≥ 70% venous sac reduction on follow-up imaging were pooled from included studies with use of random effects proportion meta-analysis. Heterogeneity across studies was assessed with the I2 statistic.

RESULTS

Forty-four studies including 1865 patients (604 (32%) males, mean age (range) 45 (24-59) years, 1125 (60%) had hereditary haemorrhagic telangiectasia (HHT)) were included in the meta-analysis. Studies included a total of 4314 PAVMs of which 4047 (94%) were treated. Studies reported morphology of 3074 PAVMs (2519 (58%) simple and 555 (13%) complex). The pooled overall immediate technical success rate for PAVM embolisation was 99%, 95% CI (98-100%) and the treatment success rate was 86%, 95% CI (84-89%). Younger age (p = 0.041), simple PAVM (0.020), and embolisation using plugs (p = 0.001) were associated with higher treatment success. Feeding artery and sac embolisation (p = 0.021) and using coils (p = 0.001) were associated with lower treatment success. There was no significant difference in recanalisation rate between different embolisation agents (OR 0.64, 95% CI -0.09- 1.38).

CONCLUSION

This meta-analysis shows that PAVM embolisation is safe and effective. Higher treatment success rates for PAVM embolisation can be achieved using plugs as the primary embolisation agent. Embolisation agent used had no effect on recanalisation rates.

Endovascular embolization of a congenital inferior phrenic artery-to-pulmonary arteriovenous malformation: a rare case report

BACKGROUND

Pulmonary arteriovenous malformation (PAVM) is abnormal arteriovenous shunts between pulmonary artery (PA) and pulmonary vein, and rarely has congenital direct communications with systemic arteries.

CASE PRESENTATION

A 33-year-old male presented to our hospital with intermittent bloody sputum with no evidence of pulmonary infection, trauma or surgery. Chest computed tomography angiography (CTA) indicated the congenital inferior phrenic artery (IPA)-to-PAVM surrounded by diffuse alveolar hemorrhage located in the lower lobe of right lung. Both the afferent PA and IPA were successfully embolized with coils. Recurrent hemoptysis did not occur during one-year follow up.

CONCLUSIONS

The congenital communication between IPA and PAVM is rare, and the abnormal direct shunt would induce hemodynamically unstable condition within PAVM. Endovascular embolization of the afferent PA and IPA is a safe and effective method for this abnormal congenital shunt in lung.

Neurological and cardiopulmonary manifestations of pulmonary arteriovenous malformations

Pulmonary arteriovenous malformations (PAVMs) are direct pulmonary artery-to-vein connections without pulmonary capillaries that result in intrapulmonary right-to-left blood shunts. Although most patients with PAVMs may be entirely asymptomatic, PAVMs can induce a series of complications involving the neurological, cardiovascular, and respiratory systems that can lead to catastrophic and often fatal clinical sequelae. In this study we review the available literature and summarize the reported PAVM-related complications among patients with PAVMs. The reviewed studies included observational studies, case studies, prospective studies, and cohort studies, and we provide an overview of PAVM-related neurological and cardiopulmonary manifestations, including stroke, cerebral abscess, transient ischemic attack, cerebral hemorrhage, migraine, seizure, dizziness, cardiac failure, arrhythmia, myocardial infarction, cough, hypoxemia, dyspnea, respiratory failure, hemoptysis, and hemothorax. Identifying and treating PAVMs before the presentation of major complication is important because this can prevent the occurrence of complications and can result in better outcomes. PAVM patients should thus be better evaluated and managed by a multidisciplinary team because they may be in a treatable phase prior to their condition becoming life-threatening.

Pulmonary arteriovenous malformation: Challenging diagnosis: A case report

Pulmonary arteriovenous malformation is characterized by an anatomic right-to-left shunt between the pulmonary arteries and veins, is characterized by an anatomic right-to-left shunt which reduces the arterial oxygen saturation and then results in clinical manifestations such as dyspnea and cyanosis. Most cases are congenital, and although uncommon, they are a significant part of the differential diagnosis of pulmonary problems like hypoxemia and lung nodules. We present a case of a 60 years old female patient who presented with the complaint of exacerbation of dry cough of 1-month duration and was diagnosed with right pulmonary arteriovenous malformation and successfully treated with surgery.

Retrospective single-arm cohort study of video-assisted thoracic surgery for treatment of idiopathic peripherally located simple type pulmonary arteriovenous malformation in 23 consecutive patients

BACKGROUND

Although case reports of video-assisted thoracic surgery (VATS) for pulmonary arteriovenous malformation (PAVM) have been published, studies analyzing more than 10 cases were limited. A retrospective single-arm cohort study was performed to investigate the efficacy of VATS in 23 consecutive patients with idiopathic peripherally located simple type PAVM.

METHODS

VATS was performed for wedge resection of 24 PAVMs in 23 patients, which included 4 males and 19 females with an age range of 25 to 80 years (mean: 59.6 ± 13.0). Two patients underwent simultaneous resection of lung carcinoma, one by wedge resection and another by lobectomy. Each medical record was analyzed according to the resected specimen, bleeding volume, postsurgical hospital stay length, duration of chest tube placement, and VATS time. The distance between pleural surface/fissure and PAVM was measured on CT, and the influence of this distance on identification of PAVM was investigated.

RESULTS

In all 23 patients, VATS was successfully performed, and the venous sac was included in each resected specimen. Bleeding volume was less than 10mL in all but one with 1900 mL bleeding volume due to simultaneous lobectomy for carcinoma, not wedge resection of PAVM. Postsurgical hospital stay length, duration of chest tube placement, and VATS time were 5.0 ± 1.4 days, 2.7 ± 0.7 days, and 49.3 ± 39.9 min, respectively. In 21 PAVMs with a distance of 1 mm or less, purple vessel or pleural bulge of PAVM was identified soon after insertion of a thoracoscope. In the remaining 3 PAVMs with a distance of 2.5 mm or more, additional efforts were needed for identification.

CONCLUSION

VATS was found to be a safe and effective to treatment for idiopathic peripherally located simple type PAVM. When the distance between pleural surface/fissure and PAVM was 2.5 mm or more, a plan and strategy for identification of PAVM should be prepared before VATS.

[Hereditary hemorrhagic telangiectasia]

Hereditary hemorrhagic telangiectasia, also known as Rendu-Osler - Weber disease, is a rare, autosomal dominant vascular disease, with prevalence of 1/5,000. The condition is characterized by muco-cutaneous telangiectasias, which are responsible for a hemorrhagic syndrome of variable severity, as well as arteriovenous malformations (AVMs) appearing in the lungs, the liver, and the nervous system. They can be the source of shunts, which may be associated with high morbidity (neurological ischemic stroke, brain abscess, high-output heart failure, biliary ischemia…). It is therefore crucial to establish a clinical diagnosis using the Curaçao criteria or molecular diagnosis based on genetic analysis of the ENG, ACVRL1, SMAD4 and GDF2 genes. In most cases, multidisciplinary management allows patients to have normal life expectancy. Advances in interventional radiology and better understanding of the pathophysiology of angiogenesis have resulted in improved therapeutic management. Anti-angiogenic treatments, such as bevacizumab (BVZ, an anti-VEGF antibody), have proven to be effective in cases involving bleeding complications and severe liver damage with cardiac repercussions. Other anti-angiogenic agents are currently being investigated, including tyrosine kinase inhibitors.

The Role of Interventional Radiology in the Diagnosis and Treatment of Pulmonary Arteriovenous Malformations

Pulmonary arteriovenous malformations (PAVMs) are uncommon, predominantly congenital direct fistulous connections between the pulmonary arteries and pulmonary veins, resulting in a right to left shunt. Patients with PAVMs are usually asymptomatic with lesions detected incidentally when radiological imaging is performed for other indications. In this review, we discuss the classification and radiological features of PAVMs as well as their treatment and follow-up options, with a particular focus on percutaneous endovascular techniques and the evolution of the available equipment for treatment.

Management of pulmonary arteriovenous malformations involves additional factors aside from the diameter of feeding arteries: a 3-year case-case retrospective analysis

Background

Pulmonary arteriovenous malformations (PAVMs) are rare but cause various manifestations. Although the diameter of feeding arteries has been linked to treatment decisions, relationships among the characteristics of PAVMs, clinical symptoms, and treatment effect remain unclear. The present study was performed to investigate how collective characteristics of PAVMs relate to clinical symptoms and to provide proper treatment recommendations for patients with PAVMs.

Methods

We retrospectively analysed 838,447 patients’ radiographic data and medical records from January 2018 to December 2020. Patients were included if a PAVM was radiographically detected for the first time in our hospital. Ordered multivariable logistic regression and hierarchical multiple regression were performed to analyse the relationships between characteristics of PAVMs and various clinical symptoms. We investigated the management of PAVMs in four tertiary university hospitals.

Results

Detection rate of PAVMs was 0.025% (207/838,447), and 37.6% of patients (78/207) also had hereditary haemorrhagic telangiectasia. Eight patients were diagnosed with bilateral diffuse PAVMs. Two hundred thirty-six lesions were detected in 199 patients, and the mean diameter of the feeding artery was 4.13 ± 1.92 mm. Most PAVMs were the simple type and located in the peripheral pulmonary area. In total, 34.3% of patients (71/207) were symptom-free; remaining patients showed various manifestations, and respiratory symptoms were most common (dyspnoea on exertion, 47.8%). The diameter of the feeding artery and the type and the number of PAVMs were correlated with hypoxaemia (P < 0.001, P < 0.001, and P = 0.037, respectively). The collective characteristics of PAVMs were not related to the severity of central nervous system symptoms (largest diameter of feeding artery, P = 0.8; largest diameter of sac, P = 0.42; number of PAVMs, P = 0.35; type of PAVMs, P = 0.99). Various symptoms were greatly relieved after treatment. The hospital investigation showed that management of PAVMs was not generally appreciated in clinical practice.

Conclusions

Our study revealed a low detection rate of PAVMs and a low degree of association with hereditary haemorrhagic telangiectasia in the general population. Considering the connection between collective characteristics of PAVMs and various clinical symptoms, clinicians should consider the type and number of PAVMs, the largest diameter of the feeding artery, and clinical symptoms when managing patients with PAVMs.

Endovascular Embolisation of Pulmonary Arteriovenous Malformation Using Amplatzer Vascular Plugs

Pulmonary arteriovenous malformation (PAVMs) are abnormal communications between pulmonary arteries and veins. The rarity of their occurrence, coupled with the risks they pose, including brain abscess, embolic stroke, and myocardial infarction, mandates that they should not be overlooked in the differential diagnosis of patients presenting with haemoptysis, dyspnea, clubbing, cyanosis, hypoxemia, or epistaxis.

We present the case of a 41-year-old local female who presented to our hospital as an outpatient with decreased oxygen saturation (SpO₂) of 70%-80% for the past two years with a final diagnosis of PAVM. The initial baseline workup showed polycythemia with a hemoglobin level of 19 mg/dL and raised hematocrit. She had extensive workup in the past two years for her polycythemia including gene mutation testing and cardiac workup which all turned out normal. Her chest X-ray (CXR) showed right lung opacity which was initially considered to be infective but it did not respond to antibiotic treatment. Later on, a CT scan of the chest was performed and findings were typical of a large PAVM which had two feeding arteries. The patient was referred to a cardiothoracic surgeon who sent the patient to the interventional radiology section for endovascular management.

The embolization procedure was then performed and both feeders were successfully embolised. After the procedure, the patient's SpO₂ levels were restored to 95%-96%, and no post-procedure complications were noted.

Platypnoea-Orthodeoxia Syndrome as an Uncommon Cause of Dyspnoea: a Literature Review

Platypnoea-Orthodeoxia syndrome (POS) is an uncommon but challenging clinical condition characterized by positional dyspnoea (platypnoea) and arterial desaturation (orthodeoxia) in the upright position that improve in the supine position. Since its first description, many cases have been reported and many conditions have been associated with this syndrome. Herein we review the clinical presentation, pathophysiology, diagnostic work-up and management of patients with POS, aiming at increasing the awareness of this often misdiagnosed condition. This article is protected by copyright. All rights reserved.

Angiographic features of pulmonary arteriovenous malformations: a new imaging classification system, BRAND, to guide embolisation

AIM

To introduce a new classification system for pulmonary arteriovenous malformations (PAVMs) based on the BRanches, ANgles and Diameter of the feeding artery (BRAND), which is intended provide a better understanding of the vascular structure of PAVMs and facilitate the selection of therapeutic strategies for embolisation.

MATERIALS AND METHODS

Twenty-one patients with PAVMs from 2005 to 2020 were reviewed retrospectively. According to angiographic morphology, classified the PAVMs using the BRAND classification.

RESULTS

A total of 41 PAVMs were treated with transcatheter embolisation. Based on the BRAND classification, there were four branches (9.8%), four acute angles (9.8%), and 32 occlusion sites >4 mm in diameter (78%). A total of 30 PAVMs (73.2%) were treated with occluders and plugs while the rest were embolised with coils (26.8%). Immediate technical success was achieved in all patients. In feeding arteries with acute angles, balloon-assisted tracking and trans-septal puncture techniques were used to facilitate the advancement of delivery systems. All origins of branches were preserved. Mean SaO₂ increased significantly from 79.5 ± 7.5% before embolisation to 92 ± 5.3% after embolisation (p<0.05). During a median follow-up of 5.4 years, two patients (9.5%) developed new PAVMs and required a second procedure. One patient (4.8%) underwent repeat embolisation due to the reperfusion of previously embolised PAVMs with coils.

CONCLUSIONS

BRAND classification is well suited to address the challenging feeding arteries of PAVMs and allow precise placement of the delivery system, leading to minimal procedural risk and high success rates.

Massive haemorrhagic complications of ruptured pulmonary arteriovenous malformations: outcomes from a 12 years' retrospective study

Background

The life-threatening haemorrhagic complications of pulmonary arteriovenous malformations (PAVMs) are extremely rare, and only described in isolated cases. This study was designed to comprehensively investigate management of ruptured PAVMs.

Methods

We retrospectively assessed clinical and imaging data of ruptured PAVMs to summarize incidence, clinical characteristics, and outcomes following embolisation between January 2008 and January 2021.

Results

Eighteen of 406 (4.4%) patients with PAVMs developed haemorrhagic complications. Twelve of 18 patients were clinically diagnosed with hereditary haemorrhagic telangiectasia (HHT). Haemorrhagic complications occurred with no clear trigger in all cases. Eight of 18 patients (44.4%) were initially misdiagnosed or had undergone early ineffective treatment. 28 lesions were detected, with 89.3% of them located in peripheral lung. Computed tomography angiography (CTA) showed indirect signs to indicate ruptured PAVMs in all cases. Lower haemoglobin concentrations were associated with the diameter of afferent arteries in the ruptured lesions. Successful embolotherapy was achieved in all cases. After embolotherapy, arterial oxygen saturation improved and bleeding was controlled (P < 0.05). The mean follow-up time was 3.2 ± 2.5 years (range, 7 months to 10 years).

Conclusions

Life threatening haemorrhagic complications of PAVMs are rare, they usually occur without a trigger and can be easily misdiagnosed. HHT and larger size of afferent arteries are major risk factors of these complications. CTA is a useful tool for diagnosis and therapeutic guidance for ruptured PAVMs. Embolotherapy is an effective therapy for this life-threatening complication.

Migrated coil expectorated 12 years after embolization of pulmonary arteriovenous malformation, due probably to abscess formation around the coil

Pulmonary arteriovenous malformations (PAVMs) are rare vascular structures providing direct capillary-free communications between pulmonary arteries and veins. Embolotherapy is indicated as a front-line therapy. We report an unusual long-term complication of coil embolization for a 44-year-old woman with hereditary hemorrhagic telangiectasia (HHT) who had repeatedly undergone the procedures for her PAVMs. She expectorated the coil which had been placed 12 years earlier and migrated to the bronchus according to the chest radiogram and bronchoscopy. Histology of the resected lung segment suggested the cavity communicating with the bronchus was the consequence of abscess formation around the coils. Even after technically successful embolization to PAVMs, long term follow-up should be necessary paying attention to the symptoms and imaging to avoid massive hemoptysis and subsequent emergency surgery.

Pulmonary arteriovenous malformations: what the interventional radiologist needs to know

Pulmonary arteriovenous malformations (PAVMs) or fistulas are rare direct pathological connections between pulmonary arterial and venous circulation. Most of PAVMs are congenital and closely associated with hereditary hemorrhagic telangiectasia, but acquired PAVMs have also been described in the literature. Diagnosis of PAVMs is a priority for clinicians, in order to prevent potentially fatal events such as cerebrovascular stroke, systemic septic embolization, hemoptysis and hemothorax. In this scenario, the radiologist plays a key role in both diagnostic and therapeutic workups of PAVMs: Chest X-ray, computed tomography and magnetic resonance are effective tools for PAVMs identification and confirmation of the suspected diagnosis. Furthermore, imaging modalities provide most of the elements for PAVMs classification according to their angioarchitecture (simple and complex) and help the clinicians in establishing which lesion requires prompt treatment and which one will benefit of imaging follow-up alone. Endovascular management of PAVMs has grown up as the first-line treatment in respect of surgery during last decades, showing lower risk of intra- and post-procedural complications and offering a wide number of treatment options and materials, ensuring effective management in virtually any clinical situation; interventional treatment aims to exclude PAVMs from pulmonary circulation, and specific technique and embolic agents should be selected according to pre-treatment imaging, in order to obtain the best procedural outcome. This paper proposes a review of the clinical and radiological features that a radiologist needs to know for PAVMs diagnosis and proper management, also showing an overview of the most common endovascular treatment strategies and embolization materials.

The three peaks in age distribution of females with pneumothorax: a nationwide database study in Japan

OBJECTIVES

Women are the minority among patients with spontaneous pneumothorax, but catamenial pneumothorax (CP) is unique to them. We aimed to clarify the clinical characteristics of female patients with spontaneous pneumothorax using a nationwide database.

METHODS

Medical records from the Japanese Diagnosis Procedure Combination database for inpatients with pneumothorax between July 2010 and March 2016 were retrospectively reviewed. Age, underlying diseases, body mass index, smoking status, laterality, number of hospitalizations and treatments were studied.

RESULTS

We identified 157 087 patients with pneumothorax, including 27 716 (17.6%) women and 129 371 (82.4%) men. The age distribution of female patients with pneumothorax had 3 peaks: 18 years, around 40 years and 80 years; male patients had 2 peaks: 18 years and 79 years. We identified 873 patients with CP; this number was not sufficient to account for the female-specific peak around 40 years. The characteristics of female patients of reproductive age were significantly different between those with and without CP. The patients with CP were older (average age: 37.9 ± 7.7 years vs 31.3 ± 11.5 years, P < 0.001), were right side dominant (right: 64.9%, left: 6.5%), had more hospitalizations (average number of hospitalizations: 1.6 ± 0.9 vs 1.3 ± 0.6, P < 0.001) and had more frequently undergone surgery (57.1% vs 37.3%, P < 0.001).

CONCLUSIONS

The age distribution of women with pneumothorax had 3 distinct peaks while that of men had 2. CP has different characteristics from other types of pneumothorax, thus requiring different treatment strategies for women of reproductive age.